Whistleblowing / consulting by email

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〇Please tell us about yourself

[Required] University Name:

[Optional] Student number:

[Optional] Department:

[Required] Disclosure of your name to the university: Make it anonymous / Use your real name (Name: 　　　　　　 )

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〇Please give us your contact information (That will not be disclosed to the university)

[Required] Disclosure of your name to the off-campus counter: Make it anonymous / Use your real name (Name: 　　　　　　)

[Required] Email address:
*A notification of acceptance will be sent to the email address you entered.

[Required] Whether the results of the investigation should be sent or not: Necessary / Unnecessary
*If you need to be contacted about the results of the investigation, please choose one of the following means of communication.
　If you wish to receive a response by phone or mail, please enter the address.
　If you wish to receive a response by email, we will contact you at the email address you have just entered

■ Email address: the same as above
■ TEL:
■ Address / Addressee's name
*Please enter your zip code, address (branch number, building name, and room number), and addressee's name

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〇What would you like to consult?
(We will report what you entered directly to the university)

[Required] Consultation Category:Harassment consultation

[Optional] Occurrence time:

[Optional] Occurrence place:

[Optional] Recognition time:

[Required] Details of consultation:

[Required] Request to the university:

[Required] Recognition of the surroundings: Yes / No

[Required] Evidence: Yes / No

*If you have any evidence, please provide it as an attachment if you don't mind
*The evidence will be submitted to the university as it is. If you wish to remain anonymous, please make sure that your information is not included.
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〇Who did that?

[Optional] University Name:

[Optional] Department:

[Optional] Job Title:

[Optional] Name:

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